In an organization providing medical care, records are often kept in the form of electronic medical records (EMRs). For example, a physician may enter notes into a computer to make them part of an EMR for a patient, or the notes are entered on a chart or are audio recorded and later transcribed and entered to become part of an EMR. The EMRs may be stored in a database and retrieved for reporting.
The reporting on the EMRs tends to be rudimentary. For example, EMRs may be viewed on a patient-by-patient basis, such as to view the existing data on the care previously provided to the patient. In some cases, reports may be generating on an aggregate level to view information on multiple patients. However, in many instances, this aggregate level of reporting is insufficient to understand the level of care being provided by an organization or to understand how to improve the quality of care. Part of the cause is that much of the data entered into the EMRs is text taken from caregiver's notes or dictations, which is difficult to quantify or report at an aggregate level.
In addition, in recent years, hospitals and other health care provider organizations have adopted evidence based clinical treatment guidelines called “medical protocols” as a part of their clinical quality programs. These guidelines are promulgated by a broad variety of health organizations, experts and industry authorities associated with specific medical specializations. These clinical treatment guidelines are utilized to diagnose and provide care for various illnesses, and in many instances hospitals and other caregivers utilize the guidelines to provide care. Many existing EMR systems are lacking in their ability to use EMRs to evaluate whether the guidelines are being followed or whether the guidelines are effective in improving care.